CARE COMMUNITY HUB

CARE COMMUNITY HUB Process Documentation Findings Round 2

Soumya Alva, Sophia Magalona, Nikki Davis &

Amanda Makulec

JSI Research & Training Institute, Inc.

October 2015

2 |

Process Documentation Contents

3

10

15

65

Background

Methodology

Results

Summary & Next Steps

15 Overall Use

19 Health Knowledge

34 Work Scheduling & Time Management

39 Achievements

46 Communication & Connectedness

52 Keeping Well

56 Overall Quality of Life

58 Supervisor App

63 Education and Learning

BACKGROUND

4 |

Process Documentation Objectives

1. Assess how well the CCH activities adhered to the

original design of the project during implementation

(fidelity) including the level of activities delivered and

participation (dose delivered and received/reach), the

level of satisfaction among participants, and quality of

program management.

2. Examine the proposed change pathways in the

theory of change to document the emergence of

preconditions, intermediate and direct outcomes, explore

the underlying drivers of change, and assess the integrity

of the project design, focusing on both CHNs and

supervisors.

3. Examine the role of the context - including the health

system - on the effect of the CCH pilot.

4. Provide data during the course of implementation to

facilitate real-time, or close to real-time, feedback to

program staff thus facilitating a continuous learning

process and program adaptation.

This document presents findings

from Round Two of the Process

Documentation (PD) conducted

from July to August 2015, in

conjunction with monitoring data

and an overview of CCH

program implementation.

BACKGROUND

5 |

•To what extent were they implemented as planned?

•What were some of the barriers and supportive factors

that affected implementation?

•What factors and processes are driving changes in health

worker knowledge, perceptions, motivation, and behavior

at this stage of project implementation?

•What is the extent of CHN exposure to the modules and

perceptions of their experience?

•What is the level of CHNs overall satisfaction with the

CHN ON THE GO app?

•What is the perceived link between exposure to the

modules and changes in CHN learning/knowledge, work

scheduling and environment, relationship with supervisors,

connectedness, confidence, and external recognition as

identified by pathways in the TOC?

•What are the systemic changes in learning and

supervisory systems which are associated with

introduction of the modules?

1. How are the CHN ON THE GO mobile application and

system level interventions being applied?

2. Are the expected results at the individual level (CHN,

supervisor), and system level (district, region) emerging as

foreseen in the pathways in the TOC?

BACKGROUND

Key Questions: What are we trying to learn?

6 |

CHN on the Go

Theory

of Change

Learning opportunities, job aids & Point of care

tools

Work planning ability & Target

achievement

Ability to communicat

e

Supervisor’s ability to

track progress

Staying well

Increased health

knowledge

Better work planning and scheduling

Better communicati

on with peers

Extrinsic motivation/

job satisfaction (job security, salary, work

environment, work load)

Module usage

frequency

INPUTS OUTPUTS INTERMEDIATE OUTCOMES DIRECT OUTCOME

ASSUMPTION: Health workers feel unmotivated and frustrated in their jobs

SYSTEM BARRIERS we cannot address: • Infrastructur

e and resource limitations

• Nurse salaries

• Formal recognition structures for GHS

• Formal promotion structures for GHS

Poor management

Resource Constraints

Isolation

Stress/ Frustration

BARRIERS

Disrespect by clients and other

HWs

Limited advancemen

t opportunitie

s

Intrinsic motivation

(confidence, connectednessr

ecognition by community/

peers, autonomy)

Supervisor’s ability to

communicate with CHNs

Recognition by supervisors

Better

supervision and management

systems

INDIRECT OUTCOME

Poor managemen

t and supervision

Better tracking

system for supervisors

Better

communication with

supervisors

Supervision App usage frequency

Limited advancemen

t opportunitie

s

Availability of learning

courses and opportunities

Number of courses/opp

ortunities GHS

recognizes

Recognition of educational credentials

System-level changes

Better CHN performance

/Nurses meet their

targets

Improved maternal, newborn, and child

health outcomes

Better quality of

care

LINE O

F AC

CO

UN

TAB

ILITY

Better work life balance

BACKGROUND

7 |

1 2

3 4

6 5

Hypotheses & Change Pathways At the individual level

CHNs will be able to make use of learning

opportunities such as e-courses through the

learning center, leading to an increase in

clinical knowledge and thus improve their ability

to perform their job. This has implications for

intrinsic motivation (greater education,

confidence in their abilities) and extrinsic

motivation (recognition by community and

supervisors).

CHNs will be able to access necessary clinical

information in the point of care module. The

module will provide CHNs with an improved

decision support system and thus improve their

ability to perform their job. Other job aids and

resources will also be made available. This has

implications for intrinsic motivation (greater

knowledge, confidence in their abilities) and

extrinsic motivation (recognition by community).

CHNs will be able to use the event calendar

module enabling them to document, plan and

review their work schedule, coordinate with

their peers and supervisors, and perform

their job better meeting pre-established

targets. This has implications for intrinsic

motivation (a more manageable

workload/improved work environment) and

extrinsic motivation (recognition by supervisors).

CHNs will document all their achievements with

regard to clinical targets met in the achievement

calendar. This will assist in better

communication with their supervisors who will

access this information through the supervisory

app either through the computer (at facilities) or

app.

Access to the “staying well” module will provide

CHNs with useful information that will help

improve their work/life balance and general

well being. This has implications for intrinsic

motivation (better work environment).

Through WhatsApp groups set up within the

districts, CHNs will also be able to better

communicate, coordinate and share ideas

with their colleagues and supervisors. This has

implications for intrinsic motivation (better work

environment and connectedness).

BACKGROUND

8 | BACKGROUND

Hypotheses & Change Pathways At the system level

Use of the supervisory app will give

supervisors the ability to monitor CHN

workloads, schedule, and achievements

resulting in a better supervision tracking

and management system –and

increased CHN-supervisor communication

and mentoring in the long run.

Increase in the number and type of

courses offered and their acceptance by

GHS as meeting educational qualifications

of CHNs results in an increase in

educational credentials of CHNs, and

greater recognition by supervisors and

the health system.

9 |

Conducted in November 2014 Nurses’ favorite modules were

WhatsApp widely used

Overall decrease in CHN workload

Gaps around link between CHN on the Go app and supervisors

What we learned from Round 1

The first round of CCH process documentation was

conducted in November 2014. Overall, both CHNs and

supervisors across all districts were excited to use the CHN

on the Go app; however, they faced technical issues with the

phone, network, and battery.

Most popular: Among CHNs, the most popular modules in

the app were the Learning Center, Planner, and the Point of

Care. CHNs also widely used WhatsApp.

Workload: The app enabled CHNs to plan and share their

daily itineraries, to communicate with other CHNs and

supervisors, and increased their clinical knowledge. CHNs

felt that the app decreased their workload.

Connecting nurses and supervisors: CHNs felt that it also

improved their relationship with other CHNs, supervisors, and

clients; CHNs felt that they did not receive any recognition

from supervisors for meeting their targets or performing their

roles.

Supervisors liked the supervisor app in principle but not all

were happy with its functioning.

Discussions related to motivation did not emerge from this

round of Process Documentation; therefore, it was explored

more in round two and further in round three.

BACKGROUND

METHODOLOGY

11 |

Project Timeline: May 2014-July 2015

MAY JUNE JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY JUN JUL

2014 2015

May - July 2014 Version 1 Training

Late July 2014 Version1 actual launch

1st week of Aug 2014 Trainings extended

November 2014 Version

2 Training

November 2014 Version 2 actual launch

ONGOING DISCUSSIONS WITH GHS, REGIONAL/DISTRICT DIRECTORS, OTHER STAKEHOLDERS

Jan – Feb 2015 Training for Volta Regional Directorate. NMC collaborating partner.

Feb-March 2015 Training for Volta/

Greater Accra RHMT. Family Health Division

home unit of CHN on the Go within GHS.

June 2015 Accreditation letter from NMC and MOU finalized

March – May 2015 National level training (GHS-FHU, HR, PPME, MOH-HR)

METHODOLOGY

12 |

BASELINE May – Aug 2014

PROJECT START May-June 2014

PD Round 1 Nov - Dec 2014

PD Round 2 July - Aug 2015

Feedback session April 2015

PROJECT END May 2016

Other data collection activities: • Monthly field interviews • Monthly usage monitoring dashboard

Magpi e-survey Dec 2015 – Jan 2016

Magpi e-survey April – May 2015

Pop-up questions June 2015

Pop-up questions Jan 2016

Feedback session PD Round 3

ENDLINE Feb 2016*

RME Timeline

METHODOLOGY

The evaluation of the CCH project is an iterative learning

process, with periodic data being subject to ongoing

discussions that eventually feed into revising project design.

The second round of process documentation triangulates

results from a series of data collection activities conducted

between January and August 2015.

*Endline survey to be conducted after App refresher

training in March 2016

13 |

Primary Data Collection

The primary data collection includes

in-depth interviews and observation

checklists by JSI and ILC Africa staff

conducted from July to August 2015

(see table, right).

Other discussions during this time

included interviews with the Volta

Regional Director, and District Directors

from Ningo Prampram, South Dayi, and

South Tongu; Registrar of the Nursing

and Midwifery Council, Asst. Director

Training) GHS HR Department, and

Director, GHS PPME; and ongoing

discussions with the Grameen

Foundation and Concern Worldwide

Ghana staff.

Nvivo was used to conduct a thematic

analysis of key informant interviews as

well as information gathered through

other discussions.

Interview type No. District

CHN interview 16 All 5 districts (Ningo

Prampram, Ada East, Ada

West, South Dayi, South

Tongu)

Supervisor

interview

8 All 5 districts

Client interview 8 Ningo Prampram and

South Tongu only

CHN

observation of

activities over

half a day

6 Ningo Prampram, South

Dayi, and South Tongu

ILC and JSI staff, July-August 2015

METHODOLOGY

How many interviews were conducted?

14 |

Additional Data Sources

Other data sources include:

• Usage data on different modules provided by

Grameen Foundation (January to July 2015)

• Monthly progress reports drafted by

Concern Worldwide Ghana team (January to

August 2015)

• Magpi e-survey on self-reported usage and

operational indicators including technical

issues (April to May 2015)

• Feedback sessions (focus group discussions

conducted by Grameen Foundation) (April

2015)

• Pop-up questions – Very short questionnaire

sent directly to nurses’ phones for self

response on satisfaction/motivation, popular

modules (June to July 2015)

Graphs were used to summarize usage and Magpi e-

survey data for each module as well as data from pop-

up questions.

Information from feedback sessions and program

implementation from monthly progress reports were

synthesized to supplement the results.

*due to data quality issues, data from 2014 is not comparable to

current usage trends

METHODOLOGY

RESULTS

16 |

Communication & Connectedness

Achievement Center

Planner

Learning Center

Point of Care

Staying Well

WhatsApp

Health Knowledge

Work Scheduling

Targets

Relationships

Keeping Well

Confidence

Recognition

Time management

Professional relationships

Emotional support

MODULES MOTIVATION

Supervisor App Monitoring and Supervision

Pathways to Change The results are summarized based on major themes that make up the

intermediate and direct outcomes outlined in the Theory of Change. The

diagram below illustrates that there is no clear pathway to motivation for

each module in the CHN on the GO app, as each module contributes to

multiple themes along the pathway. The contribution o1f each module will

be summarized under each related theme.

RESULTS

17 |

TOTAL

CHN On the Go Users

There were a total of 215

CHNs using the CHN on the

Go app and 55 supervisors

using the Supervisor App

between January and July

2015 across the five districts.

RESULTS

18 |

Self Reported

Frequency of Use

(use/week)

Usage Monitoring

(frequency per month)

Frequency of CHN On the Go Usage

Results show a discrepancy between self-reported usage

data from the Magpi e-survey and actual usage data, with

CHNs self-reporting more frequent use of the application

than indicated by the usage data. A majority of CHNs

reported using the app either everyday (29%) or three to

four times a week (35%); however, actual usage shows that

on average, the majority of users use the app only 1-5 days

per month.

While recording of usage data needs to

be rechecked, it is possible that social desirability bias may

have influenced CHNs report of their

usage of the app. This discrepancy is consistent across

usage indicators for all modules

presented in the rest of the results in this

section

RESULTS

0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

Everyday

5x

3-4x

1-2x

rarely

No

. o

f C

HN

s

Pathway Health Knowledge Confidence in Providing Services

20 | RESULTS

The Learning Center and Point of Care

modules are intended to help CHNs improve

their knowledge of health issues.

These modules were designed to update CHNs on information

to update their knowledge of maternal, newborn and child

health, and family planning issues to help them better perform

their job. The Point of care module in particular serves as an aid

for their interactions with clients.

WhatsApp was another medium through which CHNs Shared

health information among colleagues. More specific detail on

the use of WhatsApp is provided in the results section on

Communication and Connectedness section.

Health Knowledge

“The phone and the app [has been helpful to me and

everybody, because the] planner helps to plan and acquire new knowledge. [It] has been very useful.”

- CHN, Ada East

RESULTS HEALTH KNOWLEDGE

21 |

Self Reported

Frequency of Use

(use/week)

Usage Monitoring


Frequency of Point of Care Usage

A discrepancy between the self-reported and actual

usage of the Point of Care Module is also evident. With

CHNs reporting more frequent use. Most CHNs

reported using the module within the past week or two.

However, only about 50% of CHNs actually used the

Point of care module in each month between January

and July of 2015. The month of highest usage was

April which is likely due to updates made to the module

and training conducted during that month.

0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

this week

last week

2 weeks ago

more than 2

weeks ago

never

RESULTS RESULTS HEALTH KNOWLEDGE

No

. o

f C

HN

s

22 |

Favorite Point of Care Tool

In the Magpi e-survey, CHNs reported that their

most favorite section of the Point of Care module

was the Antenatal Care (ANC) content, followed by

Postnatal Care (PNC) for baby and PNC for

mother.

0%

20%

40%

60%

80%

100%

ANC PNC for baby PNC for mother


23 |

Self Reported last

time CHN read

reference material

Usage Monitoring


Frequency of Learning Center Usage

Sixteen percent of nurses reported never using the

Learning Center module , far more than the case of the

Point of Care module, but interestingly actual usage data

indicates a higher percentage of nurses actually used the

Learning Center module than the Point of Care. The majority

of nurses used this module 1-5 days each month.

Some key statistics:

● 95% installed all five FP

courses

● 78% installed all 7

MNCH courses

● In 8 of the 14 available

courses, the average

final exam score earns a

pass

● The most popular

course is FP 101, but

the course with the most

completions is Diarrheal

Disease

0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

this week

last week

2 weeks

ago

more than

2 weeks

ago

never


No

. o

f C

HN

s

24 |

Reasons for using Learning Center & Point of Care

The Learning Center allowed the nurses to read new

information and then test themselves on what they had

learned. This process helped them determine the topics they

needed to spend more time going through and where there

were gaps in their knowledge.

Aside from taking courses in the Learning Center module to

improve their health knowledge, nurses often flipped

through relevant parts of the Learning Center prior to

meeting with clients in order to refresh themselves to be

better able to deliver care.

Point of Care also served as a quick reference for CHNs to

use in front of their patients. They further show the module to

the patients so that they have a better understanding of what

the CHN is telling them when giving her diagnosis.


25 |

What the nurses are saying

“Because of the Learning Center

has courses that you can take

test and after taking the test, you

read through and then after you

retake test and then find out

whether you were able to read it

well or you didn’t read it well you

just brushed through. So at least

it helps me get knowledge about

something I never knew about or

I knew and I have forgotten

about.” -CHN Ada

“The Learning Center too, you

upgrade your knowledge on the

courses there before you go to

the field. So when you get to the

field and then you meet maybe

err….a baby, a postnatal baby,

you know what to do for the baby

with maybe infected chord or

something you know what to do

for the baby or what to tell the

mother to do for the baby.” -

CHN, Ningo Prampram

“As I said earlier on the language

barrier with the Point of Care that

has the visuals, it helps those of

them that can speak the local

language to counsel the mothers

with the visuals” -Supervisor,

Ningo Prampram

“The pictures on it maybe you know at the Point

of Care we use at the health center or you are

attending to a client ANC at home and you are

not finding something, maybe the kind of drug.

Or she has come to check, she said I missed

my menses this day then you calculate then

check, if you are pregnant then you due to

delivering this day, so pack your thing and

come. Sometimes you don’t know the thing but

you check you are able to give the right

information to the client.” -CHN, Ada


26 |

How CHNs are Accessing Information

CHN on the Go is changing the way CHNs access information

to do their work. The app makes accessing information much

easier in that CHNs no longer have to dig through books,

protocols, etc. to find answers to their questions. They can

perform a quick search and easily access what they need.

Because they don't have to carry books and flip charts with

them, they are able to utilize the app to improve their health

knowledge whenever they have a spare moment, no matter

where they are.

The peer network created by the WhatsApp groups serve as

an addition source of information where nurses can ask

questions about something they have read in the app and

have concepts and information clarified by their peers.

“Yes. It has helped me because

most of the things I will say, after

I’ve left school, I will say I’ve never

taken a book to read like holding

my hard copy to read. But with this

I can go everywhere with it and in

a car I could read. So it helps, it’s

helping me. Thus what I will say.”

–CHN, South Dayi

“Like the group was formed to upgrade our knowledge on

certain things ok. So when I heard of anything I wanted to

share on it or maybe I want to know much about it then

you tell me am sleeping oh and I also replied the person

that off your phone. That’s why me am not active there

because when send something or you WhatsApp there

then you will see another person also saying a different

thing.” - CHN Ada East/West


27 |

Long-Term Learning and Confidence in Providing Services

“[With] the Point of Care, at least it

helps you to render the best of

care. I am not a midwife but I know

how to render pregnancy care to my

clients because of the app.”

– CHN, Ada East/West “It has influenced their work because

they can easily refer to the phone

and that has boost their clinical

knowledge and gives them

confidence.”

–Supervisor, Ada East/West

As the nurses have continued to utilize the app to

increase their health knowledge, they are beginning to

internalize the information, which possibly requires

them to refer to their phone less often when providing

care. This gain in knowledge helps them to become

more confident in their ability to deliver clinical services

to their clients.

“I have used the phone for some time now and

now without the phone, there are some of the

things that is on the phone that I can do

without the phone. So with this I think when I

am with my colleagues that do not have the

phone, they will know that I have I’m on top of

them”. - CHN, South Dayi


28 |

Interactions between CHNs and Clients

Based on the observation checklist during the PD data

collection, CHNs were observed utilizing the app to educate

their clients on the following topics: Nutrition, ANC, PNC,

breastfeeding, Family Planning, Malaria Prevention and

Immunization.

While the CHNs observed did not always use the app when

providing services to their patients, they were observed

utilizing it for the visual aids that helped them better explain

health messaging topics.

During this time, clients were observed to be engaged with

the phones.


29 |

What we saw observing CHNs & clients

Next, the CHN pulled the CCH phone out of her pocket.

Using the Point of Care module, the CHN talked to the

woman about nutrition requirements for mothers. The CHN,

knowing the woman is literate, asked the woman to read what

was written on the phone page that she had previously

opened. The woman smiled and read aloud the words on the

page.

The CHN then opened to another page that showed pictures

of foods that breastfeeding mothers should eat. The woman,

smiling again, read aloud all that she saw on the phone’s

page. While reading, the woman nodded her head. The CHN

then asked the woman if she saw any pictures of ice cream

among the pictures of the food the woman should be eating.

The woman laughed and shook her head, showing that she

had not seen any pictures of ice cream.

The CHN then explained to the woman the importance of the

food that she should be eating, especially since she is

breastfeeding. The woman felt ashamed and said she would

take what the CHN said seriously. The woman apologized to

the CHN and thanked her for the advice.

-Observation of CHN and client during a home visit in Ningo

Prampram.

On this slide and the next are insights from observing

CHNs and clients. These are not meant to be representative, but provide anecdotal evidence of how

CHN On the Go is being used as part of client visits.


30 |

What we saw observing CHNs & clients

The CHN also told the women that

they should breast feed

consistently and often. The CHN

continued talking to the women as

she showed them more pictures

on the CCH phone. The CHN also

used her hands to make

demonstrations as she spoke. The

women looked keenly at the

pictures and giggled in between

seeing the pictures. One woman

held the phone in her hands while

the CHN talked to them about

proper nutrition for their babies.

–Observation of CHN in Ningo

Prampram

The CHN then showed the women a vaccination table on the

CCH phone. The CHN explained the vaccinations and drugs

that are to be given to children and advised the women to

keep their vaccination books up to date. The CHN advised the

women on the importance of vaccination for children.

After the CHN finished reading from the phone, the CHN

continued talking while holding the phone for the women to

see. The CHN would look at the phone for a few seconds

before talking directly to the women.

-Observation of CHN in Ningo Prampram

The CHN also talked to the woman about exercise while she

showed pictures of exercises on the CCH phone. The CHN

then advised the woman to get enough sleep. The woman

said her child keeps her up at night, so the woman tries to

sleep during the day when she is free. The CHN showed

more pictures to the woman about keeping the baby clean

and comfortable so that the baby can breastfeed well. The

woman laughed and told the CHN that she understands. The

CHN then closed the phone and put it in her pocket.

-Observation of CHN in Ningo Prampram


31 |

CHN confidence on the rise

From using the CHN on the GO app, there is an increased

feeling of confidence on the part of both CHNs and

clients. CHNs feel empowered by the app and like having a

resource at their fingertips. Because they can look up

information from the app, they are more confident in what

they tell their patients. Furthermore, the more they utilize the

app, the more confident they are in their ability to deliver care.

I am now confident about the things I say to

my clients I don’t have doubt when I say it

because I have learnt. I’m not thinking about

going to check whether what I have in the book

is the same as what I told them. I just tell them

and I know am right because I have learnt it.

The phone is also with me if find any difficulty,

I just pick the phone and then check.” –CHN,

Ningo Prampram

“I have had enough experience

because now when I am doing

something I have confidence of doing

something so I may say for then

experience, I will not get it a day but

continue use of the phone, I will get

more experience.” –CHN, South Dayi


32 |

Clients indicated being more confident in the information

that was being provided to them because they know it is

coming from the app. They also like having the visual aid of

the phone which helps them to better understand that the

CHNs are giving them during their interactions.

CHNs are more confident and clients are happier and trust

the information they receive

“[She] is educating you, you will

know that that is the right thing for

you to do because she does it with

evidence...she made me know

that it’s good for me to do what

she is saying rather than she

saying it without any proof.”

- Client, South Tongu “The [visit when] she used the

phone was better because you

get to understand more… Her

knowledge was better [when

she had the phone] because

she knew what she was

doing.”

–Client, Ningo Prampram

“An example is when she visited me in

the house, I saw the images on the

phone and she took time to explain what

they mean and what I have to do when I

see those signs. Before I didn’t know

some of these things but now I know.

They will only ask you what is wrong with

you and treat you, but with the phone

you will see for yourself the images

and know what it means as they

explain it to you.

– Client, Ningo Prampram

Client Perspectives


33 |

Potential The health knowledge component of the

Point of Care Module has the potential to

deploy learning materials such as

workshops and standardized protocols to all

health workers.

The Learning Center can also include more materials/topics

as well as distance learning courses with the aim of providing

nurse accreditation for the courses that they complete

through the application.

The module has the potential to deploy learning materials

such as workshops, distance learning courses, e-training

instructions, and deploying content to students.


Pathway Work Scheduling and Time Management Burden

35 |

Work Scheduling and Time Management

The Planner was designed to help CHNs set,

manage, and achieve their plans and targets

each month.

The module aims to help CHNs plan their activities through

documentation, planning, and review of work schedules, as

well as coordinating with peers and sharing with supervisors.

RESULTS RESULTS WORK SCHEDULING AND TIME MANAGEMENT

36 |

How nurses use the

planner:

Nurses used the Planner

often to see what they

need to do

They check their

itinerary often

(everyday, twice a week)

and update their itinerary

every month

Self Reported last

time CHN created an

event in the planner

Usage Monitoring


Planner usage, much like the other modules, was self

reported by the CHNs as being used much more often than

indicated by their usage data.

Lower frequency of usage for this module could be attributed

to the fact that nurses indicated that they normally update

their calendar at the beginning of each month meaning that

they likely do not make many changes to it throughout the

course of each month. No specific guidance was also

provided regarding the optimal frequency of entering

information in the Planner.

Frequency of Planner User

0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

this week

last week

2 weeks ago

more than 2

weeks ago

at CCH meeting

never

No

. o

f C

HN

s


37 |

“And the Planner tool

reminds you. It serves as

an alarm for you to begin

your work.”

– CHN, Ningo Prampram

Reasons for use The Planner has generally improved the CHN’s ability to stay

organized and plan out their tasks for each month.

CHNs indicated the benefits of having reminders for home

visits and other activities. They liked that they could keep

track of what they had accomplished and what they had left to

complete in the rest of the month. Additionally, the CHNs

knew that their supervisors could see their planners, which

helped them stay on track and be accountable.

“Because at first when the

phone wasn’t there,

sometimes you forget

especially home visit like this,

but since you brought the

phone you have your plan

on the supervisor app and

if you don’t go she will ask

you to go.”

-CHN, Ningo Prampram

“Because I set my

targets, I know what I do

at the end of the month

whether I have been able

to achieve my targets, It

helps me measure my

work done.”

- CHN, Ningo Prampram


38 |

In general, nurses and supervisors did not feel an increase in

workload. Many indicated feeling that the Planning module

helped them be more efficient with their work. Further, they

indicated that it had cut down on the communication since the

supervisors had access to the CHN’s planner and therefore

knew what activities they had planned. Some, however,

indicated that the app increased their work due to the need to

continually enter their activities throughout the month.

“There has been no

increase in my

workload.”

–CHN, Ada East/West

“When I set the targets, it

reminds me. You will select for

it to remind me daily, monthly

or weekly”

– CHN, Ada East/West

How CHN On the Go impacts workload

“My workload err I will say it has

only make the work easier because

it has increased my workload

because initially where I used to

work at first, anytime am going for

home visit as a new student I need

to carry some books along so that

in case am counseling a client or

educating her I will refer. But with

the phone, it very portable, it can

even go through my pocket, and I

think it has made my work easier.”

–CHN, South Dayi


Pathway Achievements Recognition and Respect

40 |

One of the key functions of the CHN on the Go app is to

enable CHNs to set targets and goals on courses,

coverage, and events and to monitor their progress.

Nurses are able to set their targets and goals through the

Planner and view their progress through the Achievement

Center. The Achievement Center also draws information on

course progress from the Learning Center.

Target Setting

RESULTS RESULTS ACHIEVEMENTS

41 | Note: Frequency of target setting up to the CHN

Self Reported last

time CHN set a

target in the planner

Usage Monitoring


Target Setting Usage Usage data showed mixed results between self-reporting and

actual usage. According to the usage data , on average, a

majority of CHNs did not use the target setting function at all

between January and July 2015. Self reported data show that

39% of CHNs reported that the last time they set targets in the

Planner was more than two weeks prior to the e-survey

interview. However, these two data sources are not easy to

compare in a consistent manner.

Among those CHNs who did use this function, almost all set

their targets only 1-5 days per month. A higher percentage of

CHNs set their targets in April compared to other months.

Results from the e-survey

also showed that CHNs

reported setting more

coverage targets (48%

of respondents) than

event targets (40%).

0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

this week

last week

2 weeks ago

more than 2

weeks ago

at CCH

meeting

never


No

. o

f C

HN

s

42 |

Frequency of Achievement Center Usage

During the interviews, CHNs indicated that they did not

use the Achievement Center often. In South Dayi for

example, some CHNs could not see their

achievements and therefore stopped using the

module.

Actual usage data show that almost all CHNs did not

use the Achievement Center from January to March. A

majority of CHNs were using the module in April;

however, usage decreased in the succeeding months.

This low usage of the Achievement Center could be

explained by the fact that it was the newest module to

be added to the CHN on the Go app. In addition, there

were initially issues with the target setting function of

the Planner, and results failed to display in the

Achievement Center.


No

. o

f C

HN

s

43 |

Reasons for Setting Targets

Nurses like to use the target setting functionality, because it

helps them organize what they have to do and how they

are performing. They see it as a way for self-evaluation.

Supervisors reported using this information as viewed via the

Supervisor App to keep track of nurses and to advise them on

achieving their targets, just as it was intended.

“So, when you update it, it

tells you that you have

achieved this target. It tells

us what we have achieved

and what we have not

achieved.” – CHN, Ada

East/West “The setting targets it also

helps the nurse to know this

is where I am heading to and

will I be able to achieve it by

this date. So you push the

nurse and remind them that

you are not performing and

you should do this, do this.”

–Supervisor, South Tongu

“I use the Target Setting

module. When I set the

targets, it reminds me. You

will select for it to remind me

daily, monthly or weekly. So,

when you update it, it tells

you that you have achieved

this target. It tells us what

we have achieved and what

we have not achieved.”

– CHN, Ada East/West

“There has been a

change because they

are all trying to do their

best, knowing that we

are tracking their work.

And once you set

targets/objectives then

you will be questioned

whether you have

achieved it or not.”

– Supervisor, Ada

East/West


44 |

Recognition & Respect

The Planner’s target setting function and the Achievement

center have enabled work transparency between CHNs and

their supervisors. A few nurses and supervisors talked about

recognition, respect, and acknowledgement. Only one CHN

mentioned no change in respect or recognition received from

their peers, but the rest expressed more positive change

between their clients, peers, and supervisors.

“Yes it has given us much respect

because it creates communication

and assurance between us and the

clients.” – CHN, Ada East/West

“[I can see] what they are supposed to

do with their app or application on their

phone…setting of target, reading of

some of the Learning Center, and

some of the courses and so far the

Staying well. [I can see] whether they

are reading through those materials or

not. Some of them it’s like when they

read it appears on the Supervisor’s

app... So those who are lagging behind

we try to motivate them and those who

are doing well are congratulated.”

- Supervisor, South Dayi

“If they are doing well I praise

them, and if they are not doing

well, I see that you are not even

reading these things at all, you

will have to share it with them.”

–Supervisor, Ningo Prampram


45 |

Potential of Target Setting

The target setting functionality of the CHN on the Go app has

the potential to be used as supervisory tool across all

cadres of health workers, including district supervisors

tracking sub-district supervisees, regional tracking district,

etc.

The regional and national levels of GHS have requested

updating the supervisors’ app for better monitoring based on

targets set.


Pathway Communication and Connectedness Relationships

47 |

Communication & Connectedness

In the past, communication within the health system was

limited to the head of the institutions who attended meetings.

The CCH project tries to address this gap and to increase

direct communication between supervisors and CHNs, and

among CHNs mainly through WhatsApp. The use of

WhatsApp was intended to facilitate communication and

coordination between nurses, supervisors, and clients. Pre-

set WhatsApp groups were created to facilitate these

conversations.

There is much better

direct communication

between supervisors

and CHNs, and among

CHNs

RESULTS: Communication RESULTS: Achievements RESULTS RESULTS COMMUNICATION & CONNECTEDNESS

48 |

WhatsApp Usage

In the Magpi e-survey, almost all of CHNs reported using

WhatsApp to contact their fellow CHNs. Over half (53%)

used it to contact family and friends, and a smaller

percentage (30%) to contact supervisors.

Eighty percent of CHNs reported to be active members of the

pre-set sub-district WhatsApp group; however, only 11%

percent of CHNs reported that the last time they posted

something in the WhatsApp group was a week within the

Magpi e-survey interview and 26% had never posted on the

groups.

Fifty percent reported last reading a message from the

WhatsApp group a week within the survey.

91% use WhatsApp

to contact fellow CHNs

53% contact family and friends


49 |

“The app has changed the

frequency of communication.

Like with WhatsApp, when we

want to channel any

information to the CHNs in this

sub-district, you just use the

WhatsApp. Or even if you

don’t want to call, you just

use the app.”

-CHN, Ada East/West

Reasons for use CHNs reported using the app and phone because it facilitated

communication via WhatsApp between CHNs and people

they work with as well as family and friends. They reported

that they could easily share information on events and

workshops with colleagues.

They felt connected, because it’s easier to ask questions

and to disseminate information via their CCH phones. The

program enabled knowledge sharing, as colleagues could

help provide guidance and solve cases.

A few CHNs expressed that they were not active members of

the pre-set district and/or sub-district WhatsApp groups;

however, most CHNs did find these groups useful. Some

CHNs mentioned forming their own WhatsApp groups with

family and friends and even colleagues.

For example, one nurse recounted having a group that

included their “in charge to it so when [they] get an issue

or something or [share] anything [they] want to say,

[they] discuss among [themselves] before [sending it to

the district or sub-district groups].”

“The increase is especially

about the communication

aspect. You communicate

more with your staff or the staff

that are working under you as

compared to the past.”

-Supervisor, South Tongu


50 |

“It’s good because it brings

about teamwork; you know

that whatever you are doing

your supervisors are aware.”

-Supervisor, Ada East/West

Builds Relationships The increased communication and connectedness through

the CHN on the Go app and WhatsApp has helped build

relationships between CHNs and their colleagues.

Increased transparency via WhatsApp built the relationship

between CHNs and supervisors by enabling supervisors to

monitor CHN work and to follow-up via calls or messages.

CHN relationship with their clients was improved, with clients

being happier and feeling confident about the service

they are receiving. They liked receiving more information

via visual aids on the mobile devices as opposed to just

listening to the CHN’s counseling.


51 |

“It has helped my

professional life because I

do not need to travel all the

way to my sub-district

building to discuss about

meetings or what we need to

do.” –CHN, Ada East/West

Potential WhatsApp has great potential as a communication and

information sharing tool. With its photo-sharing functionality,

CHNs can share pictures of cases with each other and use it

for group diagnosis or take photos of their itineraries and

schedules and share it via WhatsApp instead of entering the

information in the Planner.

WhatsApp has also become a medium for learning, with

nurses teaching each other through WhatsApp groups to

figure out cases, share information, etc. The ease of

communication through WhatsApp and the use of few credits

makes nurses use it more than other modules.

Supervisors also use WhatsApp to send official

communications – they take pictures of communiqués from

national, regional and district level and send to the groups for

quick dissemination. Previously, they had to wait for transport

to be available for hand delivery.


“And then when you also need help like when you meet a

client with a condition …, you could just take a photo of

whatever or whoever it is or whichever part of the body

the thing is, you just put it on the district platform, the

doctors come in or our superiors come in and then they

helps on what to do.” –CHN, Ningo Prampram

Pathway Keeping Well Emotional Support

53 | RESULTS: Keeping Well

Emotional & Social Support

One of the key goals of the CHN on the Go

app is to improve emotional and social

support through the use of the Staying Well

module and WhatsApp.

The Staying Well module of the CHN on the Go app was

designed to enable nurses to take charge of inspiring

themselves and to help deal with the stresses of work life. It

was also intended to build a sense of community through

wellness.

RESULTS: Communication RESULTS: Achievements RESULTS RESULTS KEEPING WELL

54 |

Self Reported last time

module was used

Usage Monitoring


Frequency of Staying Well Usage

Usage data on the Staying Well module was mixed. A higher percentage

of CHNs had viewed the My Wellness component of the Staying Well

module compared to No Yawa or the Daily Devotional content. Only 6% of

nurses reported never using My Wellness compared to 24% for No Yawa

and 28% for Daily Devotional. Twenty eight percent of CHNs reported last

viewing content in My Wellness within the week of the e-survey interview.

On average, across the three components, most nurses reported last

viewing content more than two weeks prior to the interview (51% for No

Yawa, 29% for My Wellness, and 40% for Daily Devotional). These results

are not consistent with actual usage data, where at least 90 CHNs out of

215 did not access the Staying Well module at all between January to July

despite an increase in usage in April and May, possibly when training was

conducted.

0%

20%

40%

60%

80%

100%

No Yawa My WellnessDaily devotional

% C

HN

resp

on

den

ts this week

last week

2 weeks ago

more than 2 weeks

ago

never

RESULTS: Keeping Well RESULTS: Communication RESULTS: Achievements RESULTS RESULTS KEEPING WELL

No

. o

f C

HN

s

55 |

“Even if you are bored at the house

and you read your WhatsApp,

there may be a post that says

have a lovely day and at least it

brings you up a little.” –CHN, Ada

East/West

“They’ve been giving me some kind of exercises

to be doing every morning about my life, how to

improve upon my well-being. They’ve been giving

me some topics to be reading to go according to it

every morning before I come to work. Every

morning I open it and what I see I go according to

it.”

–CHN, South Tongu

Reasons for Use PD interviews did not reveal much information on Staying

Well because usage was quite low among respondents. Data

from feedback sessions, however, showed that CHNs used

the CHN on the Go app and WhatsApp to release stress.

Information from Feedback sessions conducted with CHNs

showed that the Staying Well module also enabled some

CHNs to release stress, with one CHN reporting that it

reminded her to check her emotions and how to relate to her

clients and supervisors. This helps keep healthy

relationships. Daily devotionals helped them stay stress free

and wellness plans helped them keep a healthy home.

WhatsApp on the other hand served as a medium for them to

relate to people via a social media platform.

RESULTS: Keeping Well RESULTS: Communication RESULTS: Achievements RESULTS RESULTS KEEPING WELL

Overall Quality of Life

57 |

Quality of Work and Personal Life

The CHN on the Go app has impacted both the work and

personal life of the CHNs. The app helps the CHNs be more

effective and efficient in their work by helping them plan their

tasks, measure the work that they have done, and serve as a

resource that can be used to prepare for their interactions

with clients.

In terms of the benefits the app provides to their personal life,

the CHNs felt that the app helped reduced stress through the

Staying Well module and allowed them to stay connected to

their social networks of friends and family. Having such

outlets helped to better motivate the CHNs in their work.

“For my personal use. Maybe

let’s say especially when I am

down, it has something there

that…. It has some information

there that when you are

down….when you go to...It

has a certain thing there,

stress free.” -CHN, Ada

“It has changed my attitude of coming to work. Sometimes when I get bored

at work with maybe my colleagues or clients, the Stay Well says take water

and take deep breath. And the Learning Center upgrades my knowledge.

Because […] are a lot of things there which I don’t even know. I have not

seen them before, I have not heard but through the Learning Center when a

client asks me a question I would be able to answer. The Point of Care also

helps me and my client because I know there are pictures I can show to my

clients…this is how it is. Then I can further schedule with them—you have

to come this week or that week.” –CHN, Ada

RESULTS RESULTS QUALITY OF WORK AND PERSONAL LIFE

System Level Supervisor App Performance Monitoring

59 |

The Supervisor App was designed to enable

supervisors to access the progress and

activities of CHNs and use these information

to guide feedback and supervision.

Supervisor App

RESULTS: Keeping Well RESULTS: Communication RESULTS: Achievements RESULTS RESULTS SUPERVISOR APP

60 |

Frequency of Supervisor App usage

Self-reported usage of the supervisor app showed that most supervisors

last used it within one week (34%) of the Magpi e-survey interview,

followed by the week prior (26%). However, actual usage data showed

that on average at least half of supervisors never used the app at all

from January to July 2015, except for an increase in usage in April

(possibly because of training conducted). For supervisors who did use

the app, a majority only used it for 1-5 days per month.

This low use of this app may be explained by some supervisors

expressing concern during the interviews that they are not tech savvy.

Network connectivity may also be a concern limiting its use.

The app seemed to be functioning properly, with 80% of the Magpi e-

survey respondents reporting that the app displayed all nurses’ targets.

Self Reported last time

module was used

Usage Monitoring


0%

20%

40%

60%

80%

100%

CH

N r

esp

on

den

ts

This week

Last week

2 weeks ago

Longer than 2

weeks ago

At CCH Training

Never


No

. o

f su

perv

iso

rs

61 |

“Maybe in a week, once. [I

use the Supervisor’s App] at

least 45 minutes because I

have to refresh before some

of the new activity nurses

are doing comes and then

you see whatever you are

looking for.”

– Supervisor, South Tongu

Reasons for Use Supervisors reported liked the use of the app in their work

because it provided information to initiate follow up

communication on nurses’ activities through WhatsApp.

It also enhanced their supervisory role, enabling them to view

relevant information such as targets set by nurses to keep

track of their targets and provide them feedback. Supervisors

also liked being able to track CHN itineraries and photos of

activities, viewing them as proof of completion.

Supervisors also used the CHN app to familiarize

themselves with it and are interested in it. They felt

assured that nurses have GHS Protocols and all the

information required for their service delivery.

Key insight: Limited use because not all supervisors are tech savvy


62 |

Potential The supervisor app has the potential to be

an effective tool for performance monitoring

and can be used by supervisors at all levels

of the district health system.

Next steps include discussions on the end use of the

supervisor app. There is a need for supportive supervision in

the system and the app helps provide this. Discussions

surrounding the redesign of the supervisors’ app are also

necessary to better support target setting and tracking

activities as they currently occur from regional through

districts and sub-district levels to the CHNs.


“With the app you know really, you sit

in the office even outside the district

or outside the region and you can

know what is happening. But, then of

course the supportive one has to be

communicated by the application to

get to the people who need the

support. .”

– Volta, Regional Director

System Level Education and Learning

64 |

Learning Center Courses: Current Situation and Potential

Discussions with the Nursing and Midwifery Council

have resulted in the use of Learning Center courses to

obtain annual PIN certification as part of Continuous

Professional Development, but there is a need to also

include a practical component.

CHNs can now take a break from their work and go on study

leave after a certain number of years but it becomes

expensive for the GHS to finance this education and cover

CHNs in districts when they are unavailable to work. As a

result, CHNs are offered the opportunity to go on study leave

after 5 years of working. Discussions are ongoing with UHAS

and KNUST to find ways of incorporating Learning Center

courses into their curriculum so that nurses can work as they

take some of the courses through the app as part of distance

learning.

RESULTS: Keeping Well RESULTS: Communication RESULTS: Achievements RESULTS RESULTS EDUCATION & LEARNING

“And like I said it’s good. It’s

good for them, just to keep

them current. Other than

that, how many of them do

read? I started by saying

most of us when we finish

school, we put our books

aside. .”

– Asst. Director (HR),

Ghana Health Service

“We acknowledge… we run workshops to update their knowledge

so that they can renew their pins. But we cannot do that alone, so

we accredit people, like organizations like Grameen and

others…… But as a regulatory body, we have a challenge and we

have told Grameen….. we also want to say that let every module

that we put on the platform comes with its practical component.

(Need to) let the practical components match the theoretical

component that’s all.

-Registrar, Nursing & Midwifery Council

SUMMARY & NEXT STEPS

66 |

What we Learned from PD Round 2

In summary, the most popular modules among CHNs were

the Learning Center, Planner, and the Point of Care.

CHNs had mixed reviews of the Staying Well module, with

some really liking it and others not using it at all. Most CHNs

reported using the Achievement Center the least.

Results from the Pop-up survey showed that over half of

CHNs (60%) reported that the Learning Center was the most

useful module, followed by Point of Care (24%) and the

Planner (13%).


67 |

CHNs had reported some problems with their phone that

affected their use. There were problems with phones

freezing and the CHN on the Go app crashing; however,

new versions have been improved.

CHNs also pointed out that batteries run out quickly, and the

Magpi e-survey showed that almost half (47%) of

respondents said that their phones go off 1-2 days a week

because of not charging. Other reported problems included

small screens that make it difficult to see content and CHNs

not having enough credit to use their phones.

Due to previously reported network issues, CHNs were asked

about needing alternate SIM cards to maximize connectivity.

Only 1 out of 4 respondents said they needed one. This need

was highest in Ningo Prampram (40% of respondents).

Barriers CHNs Face when using CHN On the Go


68 |

Overall Impression of CHN On the Go

“It is very beneficial because it makes the work easy. And I also feel connected to friends, family, and colleagues.” – CHN, South Dayi

“The phone has helped me in general with my work…previously we were finding it difficult to send information to our in charges and our friends. But now with the phone, we are able to WhatsApp it. And with the Planner, it helps to remind us of what we have to do that day.” –CHN, Ningo Prampram

“This intervention was sent at the right

place, at the right time for the right

people… Because of this phone, our

district has become smaller… Because of

the phone we are able to send information

quickly. We are able to see conditions on

the field, take photographs and send it.”

– District Director, Ningo Prampram

From the users:

● Almost all wanted to continue to use

the app in future

● 79% of CHN respondents said the

app improved personal lives very

much (pop-up survey)

● 88% of CHN respondents said the

app improved work lives very

much (pop-up survey)


69 |

Issues to Consider Going Forward

There is a lot of interest in CCH and the app among

CHNs, supervisors, and the GHS, and CHNs and

supervisors said there were improvements to their work

and personal lives.

However, usage data showed a different picture with

inconsistencies between self-reported usage and actual

usage. There is a need to recheck the data quality and

accuracy of usage data. Also further thought is needed

on whether standards for usage need to be revised ?

Especially since specific norms for how much the app

should be used are not specifically provided to the

CHNs.

A few CHNs for example reported that they only set their

targets at the beginning of the month. There were also issues

surrounding low use of the target setting function in the

Planner and the Achievement Center. Does this mean that

CHNs and supervisors need more training on the use of

these modules?

Using the Learning Center as a means for CHNs to obtain

annual certification with the PIN, the program may need to

add a practical component to the courses as directed by

the Nursing and Midwifery Council.


70 |

Gaps to Explore in Round 3

The findings from this round highlighted

some gaps that can be explored further in

the third round of PD.

• Clarity on how much the supervisors app is currently

being used so that improvements can be made to

enhance use

• To what extent has the app changed the nature of

supervision?

• Modification of the CHN on the Go app – should it be

aligned more to current monitoring and reporting

systems and targets set at the district level?

• Ways in which the sub district can be engaged further

to provide appropriate supervision?

• Understand any changes to the ways the app is

influencing CHN behavior based on enhancements to

be made to the app in the coming months?

• Understand the need and process of transition and

sustainability of the app with regard to GHS


71 |

JULY AUG SEPT OCT NOV DEC JAN FEB MAR APR MAY

2015 2016

November 2015

Version 4 launch

Refresher training

for supervisor app

and target setting

ONGOING DISCUSSIONS WITH GHS, REGIONAL/DISTRICT DIRECTORS, OTHER STAKEHOLDERS

March – May 2016

Transition to

district, regional,

and national

levels

March 2016

Final

refresher

training led

by district

Next Steps July 2015-May 2016


For more information about the Innovations for MNCH Initiative and the CHN On the Go App, contact innovationsformnch.org

CARE COMMUNITY HUB

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